Healthcare Provider Details

I. General information

NPI: 1003273384
Provider Name (Legal Business Name): DYLAN LUKATO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2016
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

8 BOOTHILL LN
CARSON CA
90745-5609
US

V. Phone/Fax

Practice location:
  • Phone: 415-218-8041
  • Fax:
Mailing address:
  • Phone: 415-218-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA177113
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58905
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number70707
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: